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Difficulty: EasyNeurosurgery

A 32-year-old man is brought to the emergency department 45 minutes after being struck on the right side of the head with a heavy wrench during a workplace altercation. Witnesses report he lost consciousness for approximately one minute immediately after the impact, but then awoke and was able to converse normally. Over the past 15 minutes, he has become progressively lethargic and is now unresponsive to verbal commands. His blood pressure is 165/90 mmHg, and his pulse is 52/min. Neurologic examination reveals a dilated, unreactive right pupil and left-sided hemiparesis. A non-contrast CT scan of the head demonstrates a large, biconvex hyperdense mass over the right temporoparietal convexity with a 12-mm leftward midline shift. Which of the following is the most appropriate next step in the management of this patient?

  1. Urgent surgical craniotomy and hematoma evacuationAnswer
  2. B
    Admission to the intensive care unit for serial neurological observations
  3. C
    Lumbar puncture for cerebrospinal fluid drainage and pressure relief
  4. D
    Immediate intravenous administration of broad-spectrum antibiotics
  5. E
    Intravenous administration of sodium bicarbonate

Answer

Urgent surgical craniotomy and hematoma evacuation
The correct approach is urgent surgical craniotomy and hematoma evacuation. This patient has a classic presentation of an epidural hematoma, characterized by a traumatic blow to the head, a transient loss of consciousness, a lucid interval, and subsequent rapid neurological deterioration. The CT finding of a biconvex (lens-shaped) hyperdensity confirms the diagnosis. The patient is exhibiting signs of uncal herniation, including a dilated, unreactive ipsilateral pupil (due to compression of the oculomotor nerve) and contralateral hemiparesis (due to compression of the cerebral peduncle). Furthermore, the presence of hypertension and bradycardia (Cushing reflex) indicates critically elevated intracranial pressure. The definitive, life-saving treatment for a symptomatic epidural hematoma with midline shift and herniation is immediate surgical decompression and evacuation of the clot.

Step-by-Step Solution

1
Analyze the patient's history and timeline.
The patient experienced blunt head trauma, a brief loss of consciousness, a 'lucid interval' where he appeared normal, followed by a rapid neurological decline.
This specific sequence of events is the classic clinical presentation of an epidural hematoma.
2
Evaluate the physical examination and vital signs.
The patient exhibits hypertension and bradycardia (Cushing reflex), a blown (dilated and unreactive) right pupil, and left-sided hemiparesis.
These findings indicate significantly elevated intracranial pressure and active right-sided uncal herniation compressing the ipsilateral oculomotor nerve (CN III) and the cerebral peduncle.
3
Interpret the diagnostic imaging.
The non-contrast head CT shows a biconvex (lens-shaped) hyperdense mass with significant midline shift.
A biconvex hemorrhage is pathognomonic for an epidural hematoma, typically caused by the rupture of the middle meningeal artery.
4
Determine the definitive treatment.
The most appropriate next step is urgent surgical craniotomy.
Immediate evacuation of the hematoma is required to relieve the life-threatening intracranial mass effect and reverse the herniation process.

Key Concept

Diagnosis and management of epidural hematoma with uncal herniation
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Topics

Neurosurgery

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